401k Plan data: SPRINGMOOR LIFE CARE RETIREMENT COMMUNITY WELFARE BENEFIT PLAN plan

SPRINGMOOR LIFE CARE RETIREMENT COMMUNITY WELFARE BENEFIT PLAN 401k Plan overview

Plan Name	SPRINGMOOR LIFE CARE RETIREMENT COMMUNITY WELFARE BENEFIT PLAN
Plan identification number	502

SPRINGMOOR LIFE CARE RETIREMENT COMMUNITY WELFARE BENEFIT PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Life insurance Dental Vision Temporary disability (accident and sickness) Long-term disability cover Death benefits (include travel accident but not life insurance)

401k Sponsoring company profile

AMMONS SPRINGMOOR ASSOCIATES, INC. has sponsored the creation of one or more 401k plans.

Company Name: AMMONS SPRINGMOOR ASSOCIATES, INC.

Employer identification number (EIN): 561367843

NAIC Classification: 623000
NAIC Description: Nursing and Residential Care Facilities

Form 5500 Filing Information

Submission information for form 5500 for 401k plan SPRINGMOOR LIFE CARE RETIREMENT COMMUNITY WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
502 2021-01-01
502 2020-01-01
502 2019-01-01
502 2018-01-01
502 2017-01-01 KYLE DILDAY KYLE DILDAY 2018-10-09
502 2016-01-01 KYLE DILDAY KYLE DILDAY 2017-10-15
502 2015-01-01 KYLE DILDAY KYLE DILDAY 2016-10-17
502 2014-01-01 KYLE DILDAY KYLE DILDAY 2015-10-06
502 2013-01-01 KYLE DILDAY KYLE DILDAY 2014-10-14
502 2012-01-01 KYLE DILDAY KYLE DILDAY 2013-10-14
502 2011-01-01 KYLE DILDAY KYLE DILDAY 2012-10-11
502 2009-01-01 KYLE DILDAY KYLE DILDAY 2011-03-03

Plan id#	Filing Submission Date	Name of Administrator	Name of Company Sponsor	Date Sponsor Signed
502	2021-01-01
502	2020-01-01
502	2019-01-01
502	2018-01-01
502	2017-01-01	KYLE DILDAY	KYLE DILDAY	2018-10-09
502	2016-01-01	KYLE DILDAY	KYLE DILDAY	2017-10-15
502	2015-01-01	KYLE DILDAY	KYLE DILDAY	2016-10-17
502	2014-01-01	KYLE DILDAY	KYLE DILDAY	2015-10-06
502	2013-01-01	KYLE DILDAY	KYLE DILDAY	2014-10-14
502	2012-01-01	KYLE DILDAY	KYLE DILDAY	2013-10-14
502	2011-01-01	KYLE DILDAY	KYLE DILDAY	2012-10-11
502	2009-01-01	KYLE DILDAY	KYLE DILDAY	2011-03-03

Plan Statistics for SPRINGMOOR LIFE CARE RETIREMENT COMMUNITY WELFARE BENEFIT PLAN

401k plan membership statisitcs for SPRINGMOOR LIFE CARE RETIREMENT COMMUNITY WELFARE BENEFIT PLAN

Measure Date Value
2021: SPRINGMOOR LIFE CARE RETIREMENT COMMUNITY WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 0
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 0
Number of retired or separated participants receiving benefits 2021-01-01 0
Number of other retired or separated participants entitled to future benefits 2021-01-01 0
Total of all active and inactive participants 2021-01-01 0
2020: SPRINGMOOR LIFE CARE RETIREMENT COMMUNITY WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 0
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 0
Number of retired or separated participants receiving benefits 2020-01-01 0
Number of other retired or separated participants entitled to future benefits 2020-01-01 0
Total of all active and inactive participants 2020-01-01 0
2019: SPRINGMOOR LIFE CARE RETIREMENT COMMUNITY WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 0
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 0
Number of retired or separated participants receiving benefits 2019-01-01 0
Number of other retired or separated participants entitled to future benefits 2019-01-01 0
Total of all active and inactive participants 2019-01-01 0
2018: SPRINGMOOR LIFE CARE RETIREMENT COMMUNITY WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 0
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 0
Number of retired or separated participants receiving benefits 2018-01-01 0
Number of other retired or separated participants entitled to future benefits 2018-01-01 0
Total of all active and inactive participants 2018-01-01 0
2017: SPRINGMOOR LIFE CARE RETIREMENT COMMUNITY WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 0
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 0
Number of retired or separated participants receiving benefits 2017-01-01 0
Number of other retired or separated participants entitled to future benefits 2017-01-01 0
Total of all active and inactive participants 2017-01-01 0
2016: SPRINGMOOR LIFE CARE RETIREMENT COMMUNITY WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 0
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 0
Number of retired or separated participants receiving benefits 2016-01-01 0
Number of other retired or separated participants entitled to future benefits 2016-01-01 0
Total of all active and inactive participants 2016-01-01 0
2015: SPRINGMOOR LIFE CARE RETIREMENT COMMUNITY WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 0
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 0
Number of retired or separated participants receiving benefits 2015-01-01 0
Number of other retired or separated participants entitled to future benefits 2015-01-01 0
Total of all active and inactive participants 2015-01-01 0
2014: SPRINGMOOR LIFE CARE RETIREMENT COMMUNITY WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 0
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 0
Number of retired or separated participants receiving benefits 2014-01-01 0
Number of other retired or separated participants entitled to future benefits 2014-01-01 0
Total of all active and inactive participants 2014-01-01 0
2013: SPRINGMOOR LIFE CARE RETIREMENT COMMUNITY WELFARE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 260
Total of all active and inactive participants 2013-01-01 0
2012: SPRINGMOOR LIFE CARE RETIREMENT COMMUNITY WELFARE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 257
Total of all active and inactive participants 2012-01-01 0
2011: SPRINGMOOR LIFE CARE RETIREMENT COMMUNITY WELFARE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 245
Total of all active and inactive participants 2011-01-01 0
2009: SPRINGMOOR LIFE CARE RETIREMENT COMMUNITY WELFARE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 249
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 255
Total of all active and inactive participants 2009-01-01 255

Measure	Date	Value
2021: SPRINGMOOR LIFE CARE RETIREMENT COMMUNITY WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	0
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	0
Number of retired or separated participants receiving benefits	2021-01-01	0
Number of other retired or separated participants entitled to future benefits	2021-01-01	0
Total of all active and inactive participants	2021-01-01	0
2020: SPRINGMOOR LIFE CARE RETIREMENT COMMUNITY WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	0
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	0
Number of retired or separated participants receiving benefits	2020-01-01	0
Number of other retired or separated participants entitled to future benefits	2020-01-01	0
Total of all active and inactive participants	2020-01-01	0
2019: SPRINGMOOR LIFE CARE RETIREMENT COMMUNITY WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	0
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	0
Number of retired or separated participants receiving benefits	2019-01-01	0
Number of other retired or separated participants entitled to future benefits	2019-01-01	0
Total of all active and inactive participants	2019-01-01	0
2018: SPRINGMOOR LIFE CARE RETIREMENT COMMUNITY WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	0
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	0
Number of retired or separated participants receiving benefits	2018-01-01	0
Number of other retired or separated participants entitled to future benefits	2018-01-01	0
Total of all active and inactive participants	2018-01-01	0
2017: SPRINGMOOR LIFE CARE RETIREMENT COMMUNITY WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	0
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	0
Number of retired or separated participants receiving benefits	2017-01-01	0
Number of other retired or separated participants entitled to future benefits	2017-01-01	0
Total of all active and inactive participants	2017-01-01	0
2016: SPRINGMOOR LIFE CARE RETIREMENT COMMUNITY WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	0
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	0
Number of retired or separated participants receiving benefits	2016-01-01	0
Number of other retired or separated participants entitled to future benefits	2016-01-01	0
Total of all active and inactive participants	2016-01-01	0
2015: SPRINGMOOR LIFE CARE RETIREMENT COMMUNITY WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	0
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	0
Number of retired or separated participants receiving benefits	2015-01-01	0
Number of other retired or separated participants entitled to future benefits	2015-01-01	0
Total of all active and inactive participants	2015-01-01	0
2014: SPRINGMOOR LIFE CARE RETIREMENT COMMUNITY WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	0
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	0
Number of retired or separated participants receiving benefits	2014-01-01	0
Number of other retired or separated participants entitled to future benefits	2014-01-01	0
Total of all active and inactive participants	2014-01-01	0
2013: SPRINGMOOR LIFE CARE RETIREMENT COMMUNITY WELFARE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	260
Total of all active and inactive participants	2013-01-01	0
2012: SPRINGMOOR LIFE CARE RETIREMENT COMMUNITY WELFARE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	257
Total of all active and inactive participants	2012-01-01	0
2011: SPRINGMOOR LIFE CARE RETIREMENT COMMUNITY WELFARE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	245
Total of all active and inactive participants	2011-01-01	0
2009: SPRINGMOOR LIFE CARE RETIREMENT COMMUNITY WELFARE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	249
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	255
Total of all active and inactive participants	2009-01-01	255

Financial Data on SPRINGMOOR LIFE CARE RETIREMENT COMMUNITY WELFARE BENEFIT PLAN

Measure	Date	Value
2021 : SPRINGMOOR LIFE CARE RETIREMENT COMMUNITY WELFARE BENEFIT PLAN 2021 401k financial data
Total income from all sources	2021-12-31	$0
Total plan assets at end of year	2021-12-31	$1
Total plan assets at beginning of year	2021-12-31	$1
Net plan assets at end of year (total assets less liabilities)	2021-12-31	$1
Net plan assets at beginning of year (total assets less liabilities)	2021-12-31	$1
2020 : SPRINGMOOR LIFE CARE RETIREMENT COMMUNITY WELFARE BENEFIT PLAN 2020 401k financial data
Total income from all sources	2020-12-31	$0
Total plan assets at end of year	2020-12-31	$1
Total plan assets at beginning of year	2020-12-31	$1
Net plan assets at end of year (total assets less liabilities)	2020-12-31	$1
Net plan assets at beginning of year (total assets less liabilities)	2020-12-31	$1
2019 : SPRINGMOOR LIFE CARE RETIREMENT COMMUNITY WELFARE BENEFIT PLAN 2019 401k financial data
Total income from all sources	2019-12-31	$0
Total plan assets at end of year	2019-12-31	$1
Total plan assets at beginning of year	2019-12-31	$1
Net plan assets at end of year (total assets less liabilities)	2019-12-31	$1
Net plan assets at beginning of year (total assets less liabilities)	2019-12-31	$1
2018 : SPRINGMOOR LIFE CARE RETIREMENT COMMUNITY WELFARE BENEFIT PLAN 2018 401k financial data
Total income from all sources	2018-12-31	$0
Total plan assets at end of year	2018-12-31	$1
Total plan assets at beginning of year	2018-12-31	$1
Net plan assets at end of year (total assets less liabilities)	2018-12-31	$1
Net plan assets at beginning of year (total assets less liabilities)	2018-12-31	$1

Form 5500 Responses for SPRINGMOOR LIFE CARE RETIREMENT COMMUNITY WELFARE BENEFIT PLAN

2021: SPRINGMOOR LIFE CARE RETIREMENT COMMUNITY WELFARE BENEFIT PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2020: SPRINGMOOR LIFE CARE RETIREMENT COMMUNITY WELFARE BENEFIT PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2019: SPRINGMOOR LIFE CARE RETIREMENT COMMUNITY WELFARE BENEFIT PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2018: SPRINGMOOR LIFE CARE RETIREMENT COMMUNITY WELFARE BENEFIT PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2017: SPRINGMOOR LIFE CARE RETIREMENT COMMUNITY WELFARE BENEFIT PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2016: SPRINGMOOR LIFE CARE RETIREMENT COMMUNITY WELFARE BENEFIT PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2015: SPRINGMOOR LIFE CARE RETIREMENT COMMUNITY WELFARE BENEFIT PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2014: SPRINGMOOR LIFE CARE RETIREMENT COMMUNITY WELFARE BENEFIT PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2013: SPRINGMOOR LIFE CARE RETIREMENT COMMUNITY WELFARE BENEFIT PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2012: SPRINGMOOR LIFE CARE RETIREMENT COMMUNITY WELFARE BENEFIT PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2011: SPRINGMOOR LIFE CARE RETIREMENT COMMUNITY WELFARE BENEFIT PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2009: SPRINGMOOR LIFE CARE RETIREMENT COMMUNITY WELFARE BENEFIT PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )

Policy contract number

F022167

Policy instance

Insurance contract or identification number	F022167
Number of Individuals Covered	275
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $7,770
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $64,708
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,770

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

VS677

Policy instance

Insurance contract or identification number	VS677
Number of Individuals Covered	32
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $875
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $5,963
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $313

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

116894

Policy instance

Insurance contract or identification number	116894
Number of Individuals Covered	6
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $308
Other welfare benefits provided	GROUP TERM LONG TERM CARE
Welfare Benefit Premiums Paid to Carrier	USD $2,054
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $308

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

0007302601

Policy instance

Insurance contract or identification number	0007302601
Number of Individuals Covered	33
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $240
Other welfare benefits provided	WHOLE LIFE
Welfare Benefit Premiums Paid to Carrier	USD $8,379
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $134

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

5775450

Policy instance

Insurance contract or identification number	5775450
Number of Individuals Covered	342
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $14,522
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $169,325
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,261

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

5775450

Policy instance

Insurance contract or identification number	5775450
Number of Individuals Covered	342
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $15,186
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $154,082
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,593

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

0007302601

Policy instance

Insurance contract or identification number	0007302601
Number of Individuals Covered	48
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $412
Other welfare benefits provided	WHOLE LIFE
Welfare Benefit Premiums Paid to Carrier	USD $9,727
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $184

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

116894

Policy instance

Insurance contract or identification number	116894
Number of Individuals Covered	10
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $861
Other welfare benefits provided	GROUP TERM LONG TERM CARE
Welfare Benefit Premiums Paid to Carrier	USD $5,742
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $861

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

VS677

Policy instance

Insurance contract or identification number	VS677
Number of Individuals Covered	35
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $1,370
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $6,500
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $775

DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )

Policy contract number

F022167

Policy instance

Insurance contract or identification number	F022167
Number of Individuals Covered	293
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $7,309
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $62,457
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,309

DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )

Policy contract number

F022167

Policy instance

Insurance contract or identification number	F022167
Number of Individuals Covered	408
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $11,293
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $98,246
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,293

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

VS677

Policy instance

Insurance contract or identification number	VS677
Number of Individuals Covered	35
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,342
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $6,295
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $769

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

116894

Policy instance

Insurance contract or identification number	116894
Number of Individuals Covered	11
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,143
Other welfare benefits provided	GROUP TERM LONG TERM CARE
Welfare Benefit Premiums Paid to Carrier	USD $7,340
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,143

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

0007302601

Policy instance

Insurance contract or identification number	0007302601
Number of Individuals Covered	50
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $465
Other welfare benefits provided	WHOLE LIFE
Welfare Benefit Premiums Paid to Carrier	USD $11,831
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $193

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

5775450

Policy instance

Insurance contract or identification number	5775450
Number of Individuals Covered	400
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $16,140
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $137,340
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,070

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

VA677

Policy instance

Insurance contract or identification number	VA677
Number of Individuals Covered	26
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $600
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $4,960
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $365

DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )

Policy contract number

F022167

Policy instance

Insurance contract or identification number	F022167
Number of Individuals Covered	275
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $6,815
Total amount of fees paid to insurance company	USD $1,787
Welfare Benefit Premiums Paid to Carrier	USD $55,649
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,815
Amount paid for insurance broker fees	1787

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

116894

Policy instance

Insurance contract or identification number	116894
Number of Individuals Covered	6
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $671
Other welfare benefits provided	GROUP TERM LONG TERM CARE
Welfare Benefit Premiums Paid to Carrier	USD $4,470
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $671

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

0007302601

Policy instance

Insurance contract or identification number	0007302601
Number of Individuals Covered	53
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $669
Other welfare benefits provided	WHOLE LIFE
Welfare Benefit Premiums Paid to Carrier	USD $13,267
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $347

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

TM05775450

Policy instance

Insurance contract or identification number	TM05775450
Number of Individuals Covered	373
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $17,919
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ADD
Welfare Benefit Premiums Paid to Carrier	USD $143,636
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,329

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

TM05775450

Policy instance

Insurance contract or identification number	TM05775450
Number of Individuals Covered	537
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $13,294
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ADD
Welfare Benefit Premiums Paid to Carrier	USD $184,934
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,938
Insurance broker name	FLOYD LANGFORD

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

116894

Policy instance

Insurance contract or identification number	116894
Number of Individuals Covered	6
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $1,170
Other welfare benefits provided	GROUP TERM LONG TERM CARE
Welfare Benefit Premiums Paid to Carrier	USD $7,797
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,170
Insurance broker name	ROY D RAMEY

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

0007302601

Policy instance

Insurance contract or identification number	0007302601
Number of Individuals Covered	56
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $818
Other welfare benefits provided	WHOLE LIFE
Welfare Benefit Premiums Paid to Carrier	USD $13,945
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $385
Insurance broker name	ROBERT ERIC LOWDER

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

VA677

Policy instance

Insurance contract or identification number	VA677
Number of Individuals Covered	21
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $606
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $4,732
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $365
Insurance broker name	BRIAN EDWARD JUND

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

TM05775450

Policy instance

Insurance contract or identification number	TM05775450
Number of Individuals Covered	405
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $5,700
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ADD
Welfare Benefit Premiums Paid to Carrier	USD $67,500
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,500
Insurance broker name	ROBERT LOWDER

UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )

Policy contract number

7014651A

Policy instance

Insurance contract or identification number	7014651A
Number of Individuals Covered	51
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $4,415
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $20,500
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $125
Insurance broker name	TOWERS PERRIN FORSTER & CROSBY

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

VS677

Policy instance

Insurance contract or identification number	VS677
Number of Individuals Covered	21
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $915
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $8,300
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15
Insurance broker name	RICHARD RAMEY

COVENTRY HEALTH CARE OF CAROLINAS, INC. (National Association of Insurance Commissioners NAIC id number: 95321 )

Policy contract number

3185060000

Policy instance

Insurance contract or identification number	3185060000
Number of Individuals Covered	450
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $5,495
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ADD
Welfare Benefit Premiums Paid to Carrier	USD $64,103
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,495
Insurance broker name	ROY DEAN RAMEY

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

VS677

Policy instance

Insurance contract or identification number	VS677
Number of Individuals Covered	21
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $930
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $8,228
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $25
Insurance broker name	RICHARD RAMEY

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

TM05775450

Policy instance

Insurance contract or identification number	TM05775450
Number of Individuals Covered	405
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $5,821
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ADD
Welfare Benefit Premiums Paid to Carrier	USD $67,641
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,576
Insurance broker name	ROBERT LOWDER

KANSAS CITY LIFE (National Association of Insurance Commissioners NAIC id number: 65129 )

Policy contract number

GLGD-21315

Policy instance

Insurance contract or identification number	GLGD-21315
Number of Individuals Covered	281
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $2,953
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ADD
Welfare Benefit Premiums Paid to Carrier	USD $29,535
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,953
Insurance broker name	ROY DEAN RAMEY

UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )

Policy contract number

7014651A

Policy instance

Insurance contract or identification number	7014651A
Number of Individuals Covered	51
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $5,132
Total amount of fees paid to insurance company	USD $1,353
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $20,851
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $123
Amount paid for insurance broker fees	143
Insurance broker name	TOWERS PERRIN FORSTER & CROSBY

KANSAS CITY LIFE (National Association of Insurance Commissioners NAIC id number: 65129 )

Policy contract number

GLGD-21315

Policy instance

Insurance contract or identification number	GLGD-21315
Number of Individuals Covered	260
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $2,900
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ADD
Welfare Benefit Premiums Paid to Carrier	USD $29,550
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,900
Insurance broker name	ROY DEAN RAMEY

KANSAS CITY LIFE (National Association of Insurance Commissioners NAIC id number: 65129 )

Policy contract number

GLGD-21315

Policy instance

Insurance contract or identification number	GLGD-21315
Number of Individuals Covered	257
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $2,782
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ADD
Welfare Benefit Premiums Paid to Carrier	USD $27,825
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,782
Insurance broker name	ROY DEAN RAMEY

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

116894

Policy instance

Insurance contract or identification number	116894
Number of Individuals Covered	14
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $1,471
Other welfare benefits provided	OTHER SPECIFY
Welfare Benefit Premiums Paid to Carrier	USD $9,807
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

0007302601

Policy instance

Insurance contract or identification number	0007302601
Number of Individuals Covered	97
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $8,996
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $18,902
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

039607

Policy instance

Insurance contract or identification number	039607
Number of Individuals Covered	240
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $499
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	OTHER SPECIFY
Welfare Benefit Premiums Paid to Carrier	USD $1,892
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

039607

Policy instance

Insurance contract or identification number	039607
Number of Individuals Covered	255
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $2,811
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	DEATH
Welfare Benefit Premiums Paid to Carrier	USD $21,547
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )

Policy contract number

7014651A

Policy instance

Insurance contract or identification number	7014651A
Number of Individuals Covered	66
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $12,000
Total amount of fees paid to insurance company	USD $2,511
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $21,750
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	AMMONS SPRINGMOOR ASSOCIATES, INC.
Employer identification number (EIN):	561367843
NAIC Classification:	623000
NAIC Description:	Nursing and Residential Care Facilities